Clinical Psychology for Trainees https://avxhm.se/blogs/hill0 Clinical Psychology for Trainees Foundations of Science-Informed Practice Andrew C. Page UniversityofWesternAustralia,Perth Werner G. K. Stritzke UniversityofWesternAustralia,Perth Peter M. McEvoy CurtinUniversity,Perth https://avxhm.se/blogs/hill0 UniversityPrintingHouse,CambridgeCB28BS,UnitedKingdom OneLibertyPlaza,20thFloor,NewYork,NY10006,USA 477WilliamstownRoad,PortMelbourne,VIC3207,Australia 314–321,3rdFloor,Plot3,SplendorForum,JasolaDistrictCentre, NewDelhi–110025,India 103PenangRoad,#05-06/07,VisioncrestCommercial,Singapore238467 CambridgeUniversityPressispartoftheUniversityofCambridge. ItfurtherstheUniversity’smissionbydisseminatingknowledgeinthepursuitof education,learning,andresearchatthehighestinternationallevelsofexcellence. www.cambridge.org Informationonthistitle:www.cambridge.org/9781108457101 DOI:10.1017/9781108611350 ©AndrewC.Page,WernerG.K.StritzkeandPeterM.McEvoy2022 Thispublicationisincopyright.Subjecttostatutoryexception andtotheprovisionsofrelevantcollectivelicensingagreements, noreproductionofanypartmaytakeplacewithoutthewritten permissionofCambridgeUniversityPress. Firstpublished2006 Secondedition2015 ThirdEdition2022 AcataloguerecordforthispublicationisavailablefromtheBritishLibrary. LibraryofCongressCataloging-in-PublicationData Names:Page,AndrewC.(AndrewCharles),1964–author.| Stritzke,WernerG.K.,1956–author.|McEvoy,PeterM.,author. Title:Clinicalpsychologyfortrainees:foundationsofscience-informedpractice/ AndrewC.Page,UniversityofWesternAustralia,Perth,WernerG.K.Stritzke, UniversityofWesternAustralia,Perth, PeterM.McEvoy,CurtinUniversity,Perth. Description:Thirdedition.|Cambridge,UnitedKingdom;NewYork,NY: CambridgeUniversityPress,2022.|Includesbibliographical referencesandindex. Identifiers:LCCN2021054775(print)|LCCN2021054776(ebook)| ISBN9781108457101(paperback)|ISBN9781108611350(epub) Subjects:LCSH:Clinicalpsychology.|Clinicalpsychologists–Trainingof.| BISAC:PSYCHOLOGY/MentalHealth Classification:LCCRC467.2.P342022(print)|LCCRC467.2(ebook)| DDC616.89–dc23/eng/20211227 LCrecordavailableathttps://lccn.loc.gov/2021054775 LCebookrecordavailableathttps://lccn.loc.gov/2021054776 ISBN978-1-108-45710-1Paperback CambridgeUniversityPresshasnoresponsibilityforthepersistenceoraccuracyof URLsforexternalorthird-partyinternetwebsitesreferredtointhispublicationand doesnotguaranteethatanycontentonsuchwebsitesis,orwillremain,accurate orappropriate. ............................................................... Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateandup-to-date informationthatisinaccordwithacceptedstandardsandpracticeatthetimeof publication.Althoughcasehistoriesaredrawnfromactualcases,everyefforthas beenmadetodisguisetheidentitiesoftheindividualsinvolved.Nevertheless,the authors,editors,andpublisherscanmakenowarrantiesthattheinformationcon- tainedhereinistotallyfreefromerror,notleastbecauseclinicalstandardsare constantlychangingthroughresearchandregulation.Theauthors,editors,and publishersthereforedisclaimallliabilityfordirectorconsequentialdamagesresulting fromtheuseofmaterialcontainedinthisbook.Readersarestronglyadvisedtopay carefulattentiontoinformationprovidedbythemanufacturerofanydrugsor equipmentthattheyplantouse. Contents 1 AScience-InformedModelofClinical 13 Managing Ruptures in Psychology Practice 1 Therapeutic Alliance 217 2 Relatingwith Clients 12 14 Respecting the Humanity of Clients: Cross-Cultural and Ethical 3 Assessing Clients 26 Aspectsof Practice 245 4 Matching Treatments and 15 Providing Therapy ata Distance Monitoring Client Progress 49 and Working in Rural and 5 Linking Assessment to Treatment: Remote Settings 260 Case Formulation 63 16 Psychologists as 6 TreatingClients 96 Health CareProviders 271 7 Brief Interventions 128 17 Workingin Private Practice- DrClair Lawson; Clinical 8 Low Intensity Psychologist and Director; Psychological Interventions 149 Lawson Clinical Psychology 286 9 Group Treatment 157 10 Programme Evaluation 168 11 Case Management 178 References 299 12 Supervision 200 Index 343 https://avxhm.se/blogs/hill0 v Chapter A Science-Informed Model 1 of Clinical Psychology Practice There has never been a better time to train as a clinical psychologist for three reasons. First, there is an increasing response to the recognition of the unmet need in mental health which is resulting in an increase in the number of clinical psychology jobs. Second, clinical psychology is enjoying a privileged position in mental health care because of its ability to provide an evidence-base for the services it offers (Newnham & Page, 2010). Thus, despite the expense incurred by the provision of psychological services, we can show that their effectiveness assures savings that offset those costs. Third, the pandemic associated with COVID-19 has put the spotlight on evidence- based decision-making in health-care. It has been possible to model the impact of various public health interventions and some nations and states have used this to guide decision-making to good effect. Some areas have made decisions based on criteria other than the health evidence and the impact on health at the state and national level has been evident. In addition to the impacts of the disease itself, the pandemic has drawn attention to many existing unmet needs in the area of mental health (Marques et al., 2020) and ongoing, technology-driven changes have been accelerated in therapy delivery modalities and legal and reimbursement codes for therapy at a distance. The pandemic has also pointed to the need for a flexible and responsiveattitudetothedata.Forexample,someoftheearlydirepredictionsofthe impact of COVID-19 on suicide have not been supported (Pirkis et al., 2021), and reminded many that we neglected older data showing that national crises can be protective against suicide, arguably due to improved social cohesion (Botchway & Fazel, 2021)).Thisistheexcitingchallengefacingthegraduatesoftoday’sprogrammes:howwill youshapeclinicalpsychology? Consideringthefirstofthesepoints,governmentsacrosstheworldareacknowledg- ing the need to deal effectively with mental health. Within the United Kingdom, the response has been the development of an Improving Access to the Psychological Therapies(IAPT)(NHS,2021)programme.Thisinitiativeaimstodeliverinterventions for people with depression and anxiety disorders that have been approved by the National Institute of Health and Clinical Excellence (NICE). In the United States, the AffordableCareAct(ACA)aimstoimproveequitableaccesstoanimprovedqualityof mental health care. In Australia, the Better Outcomes in Mental Health Care (Department of Health, 2021) programme improves community access to quality pri- mary mental health care by providing access to allied psychological services which enables general medical practitioners to refer consumers to allied health professionals who deliver focused psychological strategies. Thus, the desire being expressed inter- nationally (and tailored to the specific contexts of each nation) is to increase access to https://avxhm.se/blogs/hill0 1 2 Chapter1:AScience-InformedModelofClinicalPsychologyPractice mentalhealthservices.Thisdesireisleadingtoanincreasingdemandformentalhealth professionals who are able to provide the treatments required. Second, there is a common theme across the international initiatives to increase the quantity of mental health care; namely a focus on quality. Funding agencies want to ensure that they receive value for money. Consequently, funding is often limited to treatments that have a strong evidence base. Private and public funders are looking to allocatescarcehealthcareresourcestoareaswherethereisanassurancethattreatmentis effective and efficient (McHugh & Barlow, 2010). The profession of clinical psychology has enjoyed a privileged position as a result of these pressures because it has a long history of accountability (Lilienfeld, Ammirati & David, 2012). Its professionals are trained in the critical skills required to evaluate evidence and research methods to generate data on both existing and new treatments (Pachana et al., 2011). The status afforded to clinical psychologists, by virtue of their long history in demonstrating the accountabilityoftheirtreatments,hasmeantthattheprofessionasawholebenefitsfrom theresearchbasedocumentingtheefficacy,effectivenessandefficiencyofpsychological treatments (Barlow, 2010;McHugh &Barlow,2010). Weareatajuncturewhenclinicalpsychologywillcarveoutapaththatwillaffectthe professionasitgoesforward(Barkham,Hardy&Mellor-Clark,2010;Castelnuovoetal., 2020; Gruber et al., 2020). The decision facing the profession is: will science-informed practice inform the future practice of clinical psychology? The perception that psych- ologyisscientificisnotuniversal(Lilienfeld,2012).Thus,willsciencecontinuetoinform thefuturepracticeofclinicalpsychology(seeLilienfeld&Basterfield,2020;Safranetal., 2011; Stewart, Chambless & Baron, 2012)? To contextualize this decision, we will now discuss arevision of the psychiatricclassificationsystem. Allen Frances chaired the committee responsible for the fourth revision of the American Psychiatric Association’s diagnostic system; the Diagnostic and Statistical Manual of the Mental Disorders (DSM-IV). After the publication of the fifth revision (i.e.,theDSM-5)hewroteabook,SavingNormal(2014),inwhichhecogentlycritiqued the new taxonomy and the malign forces which he believed to be responsible for the errors. As a psychiatrist writing from retirement, he was excluded from any decision- making,butthereisanotherlevelonwhichthebookcanberead.Muchofhisinvective is directed at the multinational pharmaceutical companies who, in his opinion, control the agenda and directly and indirectly influence the formation of diagnostic categories and the uses to which they are put. However, what is clear is that Frances has seen (perhapstoolate)thepredicamentthatpsychiatryhasfounditselfin.Inrecentyears,the number of prescriptions for medications used to treat mental health conditions has increased to meet the rising demand. Since the number of psychiatrists has remained relatively static, general practitioners have taken over the role of key provider of psychopharmacology. Psychiatrists have been relegated to the position of small players in a big market and their voice, once pre-eminent, has become one among many. For example, the head of the Royal Australian and New Zealand College of Psychiatrists echoed the same sentiment in an interview (ABC, 2014) where he noted that some groups in the community were increasingly more likely to seek advice from their GP rather than a psychiatrist. Thus, psychiatry is realizing that its pre-eminent position in mental health care has been eroded. As society has realized that the burden of mental health care is far larger than psychiatry can ever manage, it has sat by while other professionshavestepped up tothe task. Chapter1:AScience-InformedModelofClinicalPsychologyPractice 3 This cautionary tale provides clinical psychology with a window of opportunity. In thecomingyearstheprofessionofclinicalpsychologywillbesettlingitselfdownintothe newmentalhealthcareenvironment.Clearlytherearenotenoughclinicalpsychologists tomeetthementalhealthcareneedsofthetwenty-firstcentury;clearly,therewillnever be enough (Kazdin, 2011). The appropriately stringent and lengthy training of the profession will always be a limiting factor. Therefore, the exciting challenge for clinical psychologists is how to adapt themselves to this new environment. If the profession continues in the way it has been operating, it risks losing its pre-eminent role, just as psychiatryhas.Theremainderofthebookwilloutlineonepossiblefuture,wherewewill argue that clinical psychology must be a science-informed practice. By continuing to develop, evaluate and offer evidence-based treatments; by delivering treatments in a monitored error-correcting clinical practice (Lillienfeld & Basterfield, 2020; Scott & Lewis,2015);bytrainingothermentalhealthprofessionalsinevidence-basedtreatments; andbyfosteringskillsthatcomplement(ratherthanduplicate)thoseofourcolleaguesin otherprofessions,clinicalpsychologistswillbringtothementalhealthteamanexpertise that will ensure them a continuing strong future (Barlow, 2010; Ward et al., 2018; Youngstrom etal., 2017). These are both exciting and challenging times and the profession of clinical psych- ology has a bright future ahead. We are confident because psychologists know that the best predictor of future behavior is past behavior. If we consider the history of clinical psychology, we can see that a science-informed approach to practice has served the profession well. Last century, Hans Eysenck (1952) threw down the gauntlet to clinical psychologistswhenhereviewedthe24availablestudiesandconcludedprovocativelythat individuals in psychotherapy were no more likely to improve than those who did not receivetreatment.Althoughtheconclusionitselfwasquestionablegiventheextantdata (Lambert, 1976), the field responded assertively and effectively to these criticisms (e.g., Meltzoff & Kornreich, 1970). Perhaps the most effective response came from Smith, Glass,andMiller(1980).Usingmeta-analyticstatisticaltechniquestoreview475studies, they provided quantitative support for the conclusion that psychotherapy was superior tobothno-treatmentandplacebocontrolconditions(seealsoAndrews&Harvey,1981; Prioleau, Murdock & Brody, 1983). More recently, reviewers in the USA, the UK and Australiahavesoughttotakethenextstepandidentifycriteriaforempiricallysupported treatments, thereby providing listings of treatments that are “effective” for particular disorders (e.g., Andrews et al., 1999; Chambless & Hollon, 1998; Nathan & Gorman, 2015; Roth & Fonagy, 2004; Task Force on Promotion and Dissemination of Psychological Procedures, 1995). In parallel, other reviewers have collated evidence regarding the effective components of psychotherapy relationships (e.g., Norcross & Lambert, 2019; Norcross & Wampold, 2019; Orlinsky, Grawe & Parks, 1994; Orlinsky, Rønnestad & Willutzki, 2004). Together, these two lines of research provide a strong responsetoEysenck’scriticism.Whilepeoplecontinuetodebatetherelativemeritsand contributionsofthepsychotherapyrelationshipandthespecificsofparticulartherapies (e.g., Asnaani & Foa, 2014; Laska, Gurman & Wampold, 2014; Norcross & Lambert, 2019;Norcross&Wampold,2011;Wampold,2001),theconclusionthatpsychotherapy is better than no treatment, and better than a supportive caring relationship alone, is strongly supported. Thus, Eysenck’s provocative comments spurred a spirited and methodical response that allowed clinical psycholohgtytpst:o//avcxlehamrl.sye/dbelofgesn/dhilli0tself against general criticisms of